Physical Exam Pearls – 6 (Neuro, Genital, Vascular, etc.)

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Finishing up a series of random tips about performing Physical Exam, concluding with miscellaneous organ systems. 

Pelvic Exam

1.  Main error I see clinicians make is to over-diagnose cervical motion tenderness (CMT).  Don’t ask, “Does this hurt?”  Rather, distract with other conversation, while observing facial expression & overall reaction.  If you think there’s tenderness, pause with fingers still in the vagina, & repeat several times. With PID, significant discomfort occurs on every attempt; otherwise, chart “No CMT.”

While wiggling the cervix, be sure there’s absolutely no pressure applied with the outside hand (or abdominal tenderness will confound).

2.  I’ve seen a number of misdiagnoses of dysuria or dyspareunia due to incomplete examination of the external genitalia.  Lots of subtle lesions, couched between and around the labia and introitus, can be painful when exposed to urine, or during sex.  When a woman complains of pain, it’s important to have her specifically localize it as best possible.

3.  NEVER perform a stool guaiac exam for occult blood.  That’s an annual screen for persons over 50, obtained at home (without digital manipulation).  Get one on a young woman in clinic, what do you do next?  Chances are enormous it’ll be a false-positive; last thing she wants or needs is a colonoscopy. 

Male Genitalia 

1.  Testes are normally a little tender, especially the epididymis, so take that into consideration.  With true orchitis, torsion, or epididymitis, tenderness is extreme.

2.  Acute Prostatitis — tenderness is extreme.  If patient seems uncomfortable, need to distinguish true prostatic tenderness, from some men’s natural squeamishness with the exam itself.  Rotate your finger without touching the prostate.  Press on prostate without rotating your finger.  That should help you distinguish.

Can also help distinguish anal canal lesions from prostate tenderness.  If tenderness occurs while manipulating your finger without touching the prostate, it could be a subtle fissure, etc.

3.  Routine Prostate Exam  —  Debatable as to whether it’s worth doing.  Any asymmetry of size or consistency is significant, but the yield is very low.  And a normal exam certainly doesn’t reassure there’s no cancer.  A large prostate by digital exam may be asymptomatic, & men can have normal exams with uncomfortable BPH symptoms.

4.  If you do a prostate exam, NEVER test the stool for occult blood (see under “Pelvic Exam” above, substituting “he” for “she”.

Musculoskeletal

See Musculoskeletal Pain posting for detailed description of how to distinguish among bone, joint, ligament, tendon, muscle, bursa, & other soft tissue involvement.  Most clinicians are not aware of these useful principles.

Peripheral Vascular  —  Distinguish between Arterial & Venous disease

1.  Chronic Venous Insufficiency

• Pedal edema
• Hyperpigmentary skin changes lower tib-fib area & ankles
• Ulcers on same areas as above

2.  Venous Thrombosis — Deep (DVT) or Superficial

• DVT:  Pain, tenderness, or swelling over Femoral Vein (upper medial thigh)
• May occur in calf (less serious)
• Superficial thrombosis: red, warm, tender cord in calf (doesn’t cause PE)

• Look for petichiae, nail bed hemorrhages

4.  Chronic Arterial Insufficiency — pallor, loss of pulses, coolness = advanced disease.  For early detection in pt. with claudication or risk factors, try following maneuver:

• While sitting, examine feet for color & note the veins
• Lie pt. supine, elevate leg.  Apply pressure to milk veins, producing pallor.  Allow veins to refill:  pallor persisting >30 secs = arterial insufficiency.  Then…
• Have pt sit, examine foot for Venous Filling Time.  First vein should fill in 10-15 secs.  If >30 secs = Arterial Insufficiency.  If <10 secs = Venous Insufficiency (incompetent valves).  Then…
• Pt. remains sitting for 2 min.  If feet turn dusky red, it’s “Dependent Rubor” = arterial Insufficiency

1.  Main Goal — don’t be afraid of the Neuro Exam.  Remember it has 6 parts:

• Mental Status
• Cranial Nerves
• Motor
• Sensory
• Coordination (or Cerebellar Function)
• Reflexes (Deep & Superficial)

2.  Some of the above we rarely need to examine:

• Mental Status:  Only if you notice unusual behavior, thought process, affect, or cognition during the visit
• Main component of mental status exam is orientation, especially to Time.  Don’t forget to ask the year.  I’ve had 2 cases of frank Neuro disorder (acute hydrocephalus & hepatic encephalopathy), in which the patients were oriented to everything except year.
• Sensory:  Only if patient has a specific sensory complaint, or you find objective abnormalities in Romberg, gait, etc.

3.  What do we examine when?

• “Headache”:  Cranial Nerves, Coordination, Screen some Motor groups
• “Vertigo”:  Cranial Nerves, Coordination, Romberg
• “Neck / Back Pain”:  Motor Function in Arms &/or Legs, Reflexes
• “Fatigue”:  Motor Function (to R/O neurological Weakness)
• “Weakness”:  Check a few Motor groups to document objective weakness.  If so (uncommon but ominous), then Cranial Nerves, fuller Motor Exam, Reflexes
• “Falls”:  Motor, Coordination, Reflexes, Romberg (if Romberg abnormal [see below], test position sense in toes)
• “Numbness”:  Light touch or Pinprick in area of complaint.  If objective anesthesia, then Motor exam for that area.  If subjective paresthesias in dermatome, Motor & Reflexes for the extremity.
• May need to perform more in depth if objective abnormalities detected (e.g. test the anal wink reflex to r/o cord lesions or cauda equinae syndrome if new objective motor deficits in both legs, etc.)

4.  Cranial Nerve Pearls

• CN 2 (Optic):  always check for an Afferent Pupillary Defect
• CN 2:  include Peripheral Fields  (see Eye Pearls for easy method)
• CN 3, 4, 6:  EOMs go horizontal, oblique up, oblique down (not vertically up & down)
• CN 5:  Masseter & Temporal muscle strength are objective.  Test Corneal Reflex only if patient reports differences in sensation
• CN 7:  Most palsies are peripheral; but if forehead root is spared (i.e. remains strong), the palsy may be central (very rare)
• CN 8 (for “Vertigo”): Hearing acuity tests the Cochlear branch, Romberg tests Vestibular branch in legs, Past-Pointing tests Vestibular branch in arms
• CN 9,10:  Omit Gag reflex, but test it if any concern of deficit (important in terms of aspiration)

5.  Motor Exam Pearls

• Motor Exam, testing strength against resistance, is much more important than testing sensory function.
• Don’t screen by testing Handgrip.  Flexors are much stronger than extensors; the latter manifest weakness sooner.
• Always test motor function against gravity (“Handgrip” tests flexors with gravity!)
• For patient with r/o herniated disk of L-S spine, test Dorsiflexion of 1^st Toe!!!  It’s enervated by L4-L5, L5-S1 roots, the easiest disks to herniated.
• Distinguish true motor weakness from Factitious Weakness.
• Focal loss of motor strength can be neurologic, which includes “neuromuscular” (e.g. polymyositis), or due to pain, or due to musculo-tendon injuries (I saw a surgeon miss a tendon tear because he only tested active ROM, not Motor Strength)

6.  Sensory Exam Pearls (though rarely need to perform this part of Neuro exam):

• Remember the main modalities: Pinprick, Light Touch, Position Sense, Vibration
• If considering stroke in sensory cortex, test extinction & graphesthesia / stereognosis
• For position sense, test DIP in pinky or 5^th toe (most sensitive)
• For pinprick, use a sharp point on a broken-off tongue blade.  Hep B has been transmitted by using same sharp instrument on multiple patients (like the cutsie “sharps” that used to be included as screw-outs on reflex hammers, or maybe still are)

7.  Reflexes

• A “4+” DTR is pathologic (Upper Motor Neuron disorder); don’t use the term loosely.  “Hyperreflexic” isn’t just “very brisk”.  Test for clonus to confirm
• DTRs are diminished in Lower Motor Neuron disorders (e.g. radiculopathy)
• Can’t say “N0 Ankle Reflex” unless test pt. prone (the most relaxed position)
• Test for absent Anal Wink if any suspicion of cord lesion

8.  Romberg — Understand it

• Pt. stands feet together, Eyes Open.  If falls = Cerebellar lesion
• If no problem, pt. Closes Eyes.  Fall = Labyrinthine disorder OR deficit of Position Sense
• Test Position Sense to distinguish (disorders include lesions of posterior columns incl. 3° Syphilis, and Vit. B12 deficiency)
• If position sense WNL, the Romberg Fall w/ Eyes Closed = Labyrinthine d/o (e.g Labyrinthitis)

And that concludes our [long] list of random tips & pearls for performing physical exam of the various organ systems.  Hope something helped.